Provider Demographics
NPI:1740398510
Name:SANFORD, KENNETH GARY (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GARY
Last Name:SANFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:GARY
Other - Last Name:SANFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2640 E BARNETT RD
Mailing Address - Street 2:E333
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4301
Mailing Address - Country:US
Mailing Address - Phone:541-282-6770
Mailing Address - Fax:541-282-6771
Practice Address - Street 1:2825 E BARNETT ROAD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-0001
Practice Address - Country:US
Practice Address - Phone:541-282-6770
Practice Address - Fax:541-282-6771
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83634207Q00000X
ORMD27802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274568Medicaid
FL264144500Medicaid
ORR139378Medicare PIN
FL13527Medicare ID - Type Unspecified
OR274568Medicaid